State of Wisconsin - Enrollment Steps 1 and 2

JavaScript is not enabled.

JavaScript must be enabled for you to use DeltaDentalWI.com.
However, it seems JavaScript is either Disabled or not supported by your browser.
For DeltaDentalWI.com to work properly, enable JavaScript by changing your browser options, then try again.

State of Wisconsin Enrollment Steps 1 and 2

Enrollment for State & Local Retirees & Continuants

Please complete all fields. Optional fields are indicated.

If you are a local employee applying for continuant coverage, please contact your former employer.

If you are already enrolled and want to cancel or change your enrollment, please complete and return the Dental Plan Change form and/or the Vision Plan Change form.

Eligible Retiree/Continuant Information

Status

Retiree
Continuant

Retiree/Continuant First Name

MI (optional)

Last Name

Social Security Number Website security

Date of Birth

Gender

Street Address

Address Line 2 (optional)

City

State

Zip

Phone Number

Enrolling in the supplemental plans as a Retiree or Continuant is dependent upon final approval by the Wisconsin Department of Employee Trust Funds.

If you are unsure if you qualify please contact the appropriate agency.

Retirees, call WI ETF 1-877-533-5020.

Continuants, contact your HR department.

CONTINUE

Choose a Dental Plan

Choose a Vision Plan

Dependent Information

Billing